Multiple Counties In Your Zip Code

How to Upload and Attach a Document

Scan or photograph the document. Using your home
scanner or a scanner at a local copy store, scan your document
and save it in a format we can accept: .doc, .pdf, .gif, .jpg,
.jpeg or .bmp. You can also upload a photo of the document;
please make sure the photo includes the entire document and is
clear and readable. You may upload up to 5 attachments with a
maximum file size of 8MB for all attachments.

Upload the document or image. First, use the
form below to indicate which kind of document you are uploading.
Next click the 'Browse' button to find the document or image you
want to upload. After you have uploaded one item, it will be
automatically attached to your application. At that point, you'll
have the option to upload additional items.

Site map

All of the pages in the plan selection and enrollment tool
are listed below. To return to a previous step, please use the back
button at the bottom of the page.

Get Started

Census Information

SEP qualifying events

View Plans

Plans offered in your area

Enroll

Getting ready to enroll

Applicant information

Contact information

Statement of accountability

Broker Assistance Details

Finish up

Signature

Payment

Application summary

Please correct errors

Please correct the errors on this page before using the Save
button. After you have corrected all errors, click the Save button
again.

About Enrolling in 2017
Plans

We're sorry, but 2017 plan enrollment is
not available on this website.

Optional Coverage Premium Breakdown

Medical Plan Premium Breakdown

Total Monthly Premium Breakdown

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cleared out any data you entered on the form.

PCP Information Missing

We need more information about your PCP selection. For each
applicant on the plan, please do one of the following:

Select a PCP now by clicking the "Launch Provider Search
in a New Window" button for that applicant.

Click "No" for the question "Would you like to select a
PCP for (name)?". Health Net will select a PCP for that applicant.

Health Net Dental Disclaimer

You are now leaving
Health Net
's website and accessing a website that is managed by Dental
Benefit Providers, Inc and its affiliates (DBP). Please review the
specific Terms of Use and Privacy Policies that govern the user of
the DBP website.

What is a qualified interpreter?

A qualified interpreter should: (a) have the vocabulary
equivalent of a native speaker that has received an advanced
education (college or university equivalent) in the non-English
language. (b) be able to demonstrate cultural sensitivity in
their communication, taking into consideration that every language
encompasses a wide range of variation (c) have native speaker
language skills (native speaker language skills are developed by
growing up or functioning in a language community) and (d)
have corresponding reading and writing skills in the non-English
language (the reading and writing skills would be demonstrated by
advanced education in the native language).

Acceptable proof documents

Current California driver's license or identification
card.

Current and valid California vehicle registration form in
the applicant's name.

Evidence the applicant is employed in California.

Evidence the applicant has registered with a public or
private employment agency in California.

Evidence that the applicant has enrolled his or her
children in an California school.

Evidence that the applicant is receiving public assistance
in California.

Voter registration form of receipt, voter notification
card or an abstract of a voter registration.

Current California utility bill in the applicant's name.

Current California rent or mortgage payment receipt in the
applicant's name. Rent receipts provided by a relative shall not
be accepted.

Mortgage deed showing primary residency.

Lease agreement in the applicant's name.

Government mail in the applicant's name (SSA statement,
DMV notice, etc.).

Cell phone bill.

Credit card statement.

Bank statement or canceled check with printed name and
address.

US Postal Service change of address confirmation letter.

Moving company contract or receipt showing your address.

If you're living in the home of another person, like a
family member, friend or roommate, you may send a letter/statement
from that person stating that you live with them and aren't just
temporarily visiting. This person must prove their own residency
by including one of the documents listed above.

If you're homeless or in transitional housing, you may
submit a letter or statement from another resident of the same
state, stating that they know where you live and can verify that
you live in the area and aren't just temporarily visiting. This
person must prove their own residency by including one of the
documents listed above.

Letter from a local non-profit social services provider
(excluding non-profit health care providers) or government entity
(including a shelter) that can verify that you live in the area
and aren't just visiting.

Enrolling with Disabled Dependents

If your family includes a disabled dependent over 26 years
old, we would like to help you enroll. Please call
[1-877-878-7983] to speak to an enrollment
specialist.

Your actual effective date may be different from your requested effective date. Your actual effective date is subject to you meeting the regulatory requirements for a "Special Enrollment Qualifying Event." In order to qualify for a "Special Enrollment," you must show proof of your qualifying event (e.g., if your qualifying event is a marriage, you must provide a copy of your marriage license, etc.). You must submit all supporting documentation WITH your application. Applications submitted without appropriate documentation cannot be processed. All documents (application and supporting documentation) must be submitted at the same time and through the same method (online application, envelope/email/fax). If supporting documentation is sent separate from the application there is no guarantee that it will be matched to the application.